AMA meeting: Doctors get to see how ethics bar is set
■ An AMA-sponsored fellowship adds to its online curriculum the study of how ethics policy is made at the Annual Meeting.
Chicago -- When St. Louis anesthesiologist Joseph F. Kras, MD, rose to speak at a House of Delegates reference committee meeting, he testified against the adoption of a Council on Ethical and Judicial Affairs report. But he was not just expressing his viewpoint; he was doing his homework.
Dr. Kras' visit to the AMA Annual Meeting in June was part of an online bioethics training program co-sponsored by the Medical College of Wisconsin and the American Medical Association.
The four-course AMA-MCW Online Fellowship in Physician Ethics and Professionalism, started in 2002, is not alone in offering Internet-based bioethics training. But the program, open only to doctors, is unique in that it gears its offerings toward the pragmatic concerns of practicing physicians who take on responsibilities related to ethics. The fellowship also highlights the importance of physician organizations in codifying professional ethical standards.
While the rest of the instruction is conducted online, program fellows must see the AMA's policy-making in action in Chicago and write a short paper analyzing one of the proposed ethics policies. They get to meet CEJA members, sit in on some of the council's planning meetings and watch delegates debate in reference committee and on the house floor.
"What we're doing here is creating a cadre of doctors who understand very well how the AMA works and what its social role is with regard to professionalism and professional standards," said Matthew K. Wynia, MD, MPH, co-director of the fellowship program and director of the AMA's Institute for Ethics. "Every person who comes sees some policies they favor get through and sees some policies they favor get turned back, and they see the whole sausage-making process of deliberative democracy in action. And I think that's a powerful lesson you can't get any other way except to watch it happen."
More than 20 doctors have graduated from the fellowship program. Eight have gone on to pursue a master's degree in bioethics at MCW, which requires completing another four classes online. One course all fellows must take is called "History and Meaning of Ethics and Professionalism in Medicine," which Dr. Wynia teaches.
"Professionalism is inherently a group activity, so we spend a lot of time exploring the difference between an individual's swearing an oath and the profession's adopting a code that applies to everyone, and to what extent codes supersede individuals' own standards," Dr. Wynia said. "We look at a set of ethical issues -- physician participation in torture and capital punishment, the problem of dual loyalties -- that are very important to physicians as a group and not the same as the issues that show up in your typical bioethics coursework."
Meeting practical needs
Dr. Kras became interested in the fellowship program when he took over as director of residency education for the anesthesiology department at Washington University in St. Louis School of Medicine. Responsible for training and evaluating medical residents on professionalism and ethics, Dr. Kras said he felt "not totally qualified." Now he is one paper short of completing the fellowship program and plans to pursue the bioethics master's degree at MCW. Each of the fellowship courses costs about $2,000.
Dr. Kras, an AMA member, said he had not really understood how the Association crafts ethics standards before joining the fellowship program. While CEJA's ethical opinions go through months, and sometimes years, of exhaustive research and careful formulation, Dr. Kras was struck by the seriousness with which delegates approached proposals covering matters ranging from industry funding of continuing medical education to end-of-life care.
"I've been impressed by the level of involvement and the sophistication exhibited by the physician delegates," Dr. Kras said. "They come to this House of Delegates meeting very prepared, and they know what they're talking about. It's obvious they've worked hard on these issues."
Studying CEJA and the AMA policy-making process up close is of special value to doctors, said Arthur R. Derse, MD, co-director of the fellowship program.
"One of the complaints we often hear from students is that we will talk about cases and they will say, 'Just tell us what to do in black and white,' " said Dr. Derse, director for medical and legal affairs at the MCW Center for the Study of Bioethics. "CEJA gets as close to that as possible in medicine, offering practical advice on what do, step by step."
Walter Limehouse, MD, attended the 2008 Annual Meeting as part of the fellowship, which he took to help with his work chairing the ethics committee at the Medical University of South Carolina. He called the diversity of specialties and practice settings among delegates impressive.
What did he think after seeing the sometimes contentious ethics policy-making process in action?
"Morality reflects the community in which we live," said Dr. Limehouse, assistant professor of emergency medicine at MUSC. "And you're going to have people who have strident or differing opinions, but ultimately to have this be a democratically chosen route, I think it's actually best for the profession."